INTRAPERITONEALIZATION OF THE URETER DURING LAPAROSCOPIC URETEROLYSIS: A MODIFICATION OF THE TECHNIQUE

Abstract

A 41-year-old man presented with a 3-month history of nocturia. Serum creatinine was 5.5 mg./dl. (normal 0.5 to 1.6) and blood urea nitrogen was 51 mg./dl. (normal 5 to 23). Ultrasound showed that the right kidney had moderate hydronephrosis, whereas the left kidney was atrophic. The severe and long stricture in the right middle ureter was detected on retrograde pyelography (fig. 1). A periureteral mass was demonstrated on computerized tomography. Percutaneous nephrostomy was inserted into the right kidney to relieve obstruction. After normal renal function resumed, the patient was placed in the semi-flank position, pneumoperitoneum with carbon dioxide was achieved and 3 laparoscopic ports were used. The line of Toldt was incised and the right colon was reflected medially. The thickened and widened mid ureter was completely dissected between the ureteropelvic junction and common iliac vessels. During the dissection, normal ureter was observed just below and above the involved ureteral segment. Histological analysis of the biopsies from periureteral tissue revealed chronic inflammation and fibrosis. The involved ureter was completely peeled away, and the fibrotic tissue, and right colon and cecum were passed under it, and the right colon was fixed to the abdominal wall with a 10 mm. hernia stapler. A drain was placed. There were no complications and operative time was 200 minutes. The drain was removed on postoperative day 4, and the patient was discharged from the hospital on postoperative day 5. Antegrade pyelography performed 1 month later showed decreased hydronephrosis and a normal ureteral passage. Therefore, percutaneous nephrostomy was removed. At 10-month followup excretory urography showed a moderately lateralized ureter from the spinal column with no evidence of obstruction (fig. 2).